9-Month Well-Child
Presents for a 9-month well-child check-up
Accompanied by:
Past medical history:
Medications:
Allergies:
Family history:
Known risk factors:
Current symptoms or caregiver concerns:
NUTRITION:
Breastfeeding: , feeds daily
Vitamin D 400 IU/day (if breastfeeding):
Formula feeding (700-950 ml or 24-32 oz): daily, type:
Iron supplement (if prematurity):
Vegeterian diet:
Appetite:
Counseling:
- Eat fruits, vegetables, cow's milk product
- Explore textures
- Avoid foods high in sugar or salt
- Avoid small, hard pieces / choking prevention
- Avoid juice
- Promote independent/self-feeding
- Encourage transition from bottle to cup
- Avoid bottles in bed
EDUCATION AND ADVICE:
Sleep (11-14 hrs per day): total hrs per day
Sleep habits: , , ,
Living with: ,
Parenting/bonding:
Family conflict/stress:
Second hand smoke exposure:
Complementary/alternative medicine:
Counseling:
- Encourage reading
- Avoid screens
- Promote physical activity
- Poison prevention (poison control center)
- Car seat facing back
- Burn pervention
- Protect electric plugs/cords
- Attend during baths
- Safe sleep (avoid bed sharing, crib safety)
- Limit sun exposure / sunscreens
- Dental cleaning
- Fever advice
DEVELOPMENT:
Looks for an object seen hidden:
Cries or shouts for attention:
Babbles a series of different sounds (e.g. baba, duhduh):
Responds differently to diferent to people:
Makes sounds/gestures to get attention or help:
Stands with support when helped into standing position:
Sits without support:
Uses both hands equally:
Opposes thumb and fingers when grasps objects and finger foods:
Plays social games (e.g. nose touching, peck-a-boo):
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Measurements: length: cm - perc, weight: kg - perc, head circ: cm - perc
Head: fontanelles ,
Eyes: -R: , -L: , , , red reflex , corneal light reflex , fix and follow test
Ears: -R: , -L:
Nose: , , discharge ,
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Genital: , testicles , penis
Extremities: , , cap refill , Barlow , Ortolani
Skin:
Musculoskeletal: joints ,
Neurologic: cranial nerves , global motricity , muscle tone , gait
Mental status: , , reactive to
Developmental milestones: motor: , communication: , social/emotional: , cognitive: , adaptive:
ASSESSMENT:
DDx:
PLAN:
- Blood work: if premature ou birth weight < 2500g, if at risk, if HBsAg positive mother
- Caregiver questions answered
- Iron supplementation if not consuming iron-rich foods or at risk
- Vitamin D supplementation if breastfeeding or premature
- Referral to resources and support for parents if needed
- Follow-up in